The Journal of Thoracic and Cardiovascular Surgery Volume 117, Number 6 But if with this tenn we state that any stenotic vessel has to be grafted, regardless of its importance and size, without any demonstration of ischemia in the territory, this definition of "complete revascularization" has to be forgotten. Today we have at our disposition many tools to properly investigate the importance of a stenosis, and complete revascularization (interventional, surgical, or combined) of all ischemic territo- ries is always our goal. However, the timing can change and the strategy can differ from patient to patient. In our article I thought that the real problem was focused not on the surgical indication (single LAD disease or multi- ple-vessel disease), which can be debatable, but on the future of the graft. (Is this approach able to guarantee satisfying per- meability of the graft? Can this strategy be considered safe and reproducible?) For this reason I mixed all my patients, but the patients with "multiple-vessel disease" in this group, with only a few exceptions (hybrid procedures), are not the same patients we operate on every day in our daily practice. Antonio Maria Calafiore Department of Cardiac Surgery San Camillo de' Lellis Hospital Via Forlanini 50 Chieti 66100, Italy 12/8/97384 The use of the calcium antagonist nicardipine in arterial coronary bypass surgery To the Editor: In the December 1998 issue of the Journal, Acar, l Possati, 2 and their associates independently provided important data on the 5-year patency rate of the radial artery graft. Both groups acknowledge the impressive spastic character- istics of this arterial conduit and advocate perioperative release of spasm and routine administration of the calcium antagonist diltiazem to the patients for 1 year or more. Interruption of this treatment after 1 year or later during fol- low-up did not seem to adversely influence either clinical out- come or 5-year patency. This observation is related to the apparent loss of reactivity of the radial graft over time. The use of antispasmodic drugs for patients receiving arte- rial grafts is a common practice, although so far no study has demonstrated its value on the surgical outcome, keeping in mind that "spasm" may be confounded by other factors such as surgical technique, familiarity with arterial grafts, and peri- operative conduit preparation. Since 1994, we have been using nicardipine hydrochloride, the first intravenously administered dihydropyridine calcium channel antagonist, for sequential or bilateral internal thoracic artery grafting. The patients are started perioperatively on intravenous nicardipine hydrochloride (0.25 Ilg/kg per minute) after a 1 mg intra- venous bolus. The drug is titrated according to the systemic vascular resistance and discontinued on the second postoper- ative day. For patients receiving a radial artery graft, we added to this protocol gentle hydrostatic dilatation of the conduit with 1% papaverine and oral administration of nicardipine 20 to 30 mg three times a day after discontinuation of intra- Letters to the Editor 1227 venous perfusion on day 2. The first 50 patients undergoing myocardial revascularization with a radial graft using that protocol were observed. A total of 150 anastomoses were per- fonned with a mean of 3.0 anastomoses per patient, and 108 arterial grafts were used for the completion of 111 coronary distal anastomoses. Fifty radial arteries were used for 52 dis- tal anastomoses, and 36 venous grafts were used for 39 distal anastomoses. The radial artery was placed on the obtuse mar- ginal branch in 58% of cases, diagonal branches in 13%, and the right coronary artery in 29%. Proximal anastomoses were done directly on the aorta in 80% of cases. The operative mortality was 4% because of 2 cases of ful- minant pulmonary sepsis. There was no evidence of perioper- ative myocardial infarction or arterial graft hypoperfusion syndrome. Mean creatine kinase MB level at 18 hours was 36 IlgIL. Neither ischemic anomalies of the electrocardiogram nor wall motion abnonnalities on discharge transthoracic echocardiography were detected. Angiography perfonned in the last 20 patients showed a 98% (51/52) penneability rate for all grafts. Nineteen of 20 radial grafts were patent. A mod- erate spasm (40%) developed in the middle part of the conduit in one radial artery. Our experience with the radial artery is part of a larger experience with the perioperative use of nicardipine in more than 550 cases of bilateral or sequential internal thoracic artery grafting. This protocol has virtually eliminated internal thoracic artery spasm or hypoperfusion in our practice. Nicardipine has several potential advantages over diltiazem. Nicardipine is a more potent and selective arteriolar vasodila- tory agent, which also has the capability to inhibit endothelin- induced vasoconstriction. 3 This drug has neither chronotrop- ic, dromotropic, nor inotropic negative effects. Its short action duration makes it convenient for perioperative management, and it is well tolerated in association with blockers in the routine management of patients with coronary artery disease. Nicardipine also has a documented cardioprotective effect on ischemic myocardium, and some data suggest cardioprotec- tive effects during cardioplegic cardiac arrest. 4 We therefore suggest that the time has come to assess the real need for anti- spasmodic drugs in arterial coronary bypass grafting and to determine the most adequate pharmacologic management for patients receiving arterial grafts such as the radial artery. M. A. Radermecker, MD" T. Grenade, MD" R. Larbuisson, MIY> R. Limet, MD" Department of Cardiovascular Surgery" Department of AnesthesiologY' CHU du Sart-Tilman 4000 Liege, Belgium REFERENCES 1. Acar C, Ramsheyi A, Pagny JY, Jebara Y, Barrier P, Fabiani IN, et al. The radial artery for coronary artery bypass grafting: clinical and angiographic results at five years. J Thorac Cardiovasc Surg 1998;116:981-9. 2. Possati G. Gaudino M, Alessandrini F, Luciani N. Glieca F. Trani C. et al. Midterm clinical and angiographic results of radial artery